Postgrad Med J: first published as 10.1136/pgmj.11.114.150 on 1 April 1935. Downloaded from 150 POST-GRADUATE MEDICAL JOURNAL April, 1935 JACKSONIAN EPILEPSY. A background and a post-script. By GEOFFREY JEFFERSON, M.S. (Lond.), F.R.C.S. (Hon. Neurological Surgeon, Manchester Royal Infirmary; Hon. Surgeon, The National Hospital, Queen Square, London.) In the year I827 there appeared a thesis for the degree of Doctor of Medicine in the Faculty of Medicine of Paris. It was written by L-F. Bravais of Annonay in the Department of Ardeche and was entitled "Researches on the symptoms and treatment of Hemiplegic Epilepsy"; it was based on the observations of the author on certain epileptic subjects in the Hopital Bicktre. This thesis proved to be, for those days, a close clinical study and record of a series of cases in which the convulsions were localized to one side of the body or even to one limb. Localized epilepsy was no new observation for it had been mentioned by Hippocrates, whilst Galen had found that the tying of a ligature round a limb served to prevent an epileptic attack provided that that limb was the site of origin of a seizure. These were early but isolated observations, and the immense litera- ture of epilepsy gathering volume throughout the ages has little or no message for us because it was concerned with bare clinical records and with empirical methods of treatment. Neuro-pathology had not yet been born, and so it comes about that many interestingly described cases are robbed of interest because no attempt was made by copyright. to connect pathological cause and clinical effect. It was to be left to the magis- terial brain of Hughlings Jackson to found not merely a natural philosophy for epilepsy, but to help to unravel the apparently insoluble mystery of the workings of the cerebral hemispheres. How he came to do this requires a statement of the state of knowledge, so far as we can reconstruct it to-day, at the time when he commenced his work. It is for this reason that reference has been made already to Bravais, and indeed Bravais' work calls for more than passing com- ment. for French authors in particular are apt to designate focal epilepsy as http://pmj.bmj.com/ " pilepsie Bravais-Jacksonienne." We ought, therefore, to see what proper claim there is to the linking of one name with the other, how far the views of the one were held by the other, what new thing Jackson had to add to the observa- tions of a young man who antedated him by nearly forty years. The reader who turns to Bravais' thesis in the hope of finding gold (and who does not turn to some old thesis without keen anticipation of discovery) will be only partly rewarded. This paper is none the less an important one; on September 24, 2021 by guest. Protected it is the first serious study of a particuiar type of epilepsy, and the recognition of one variety as worthy of a special memoir marks the beginning of modern conceptions of convulsive attacks. He commences well. "Having lived some time amidst epileptics we are compelled to know well their attacks, to study the march, to distinguish the symptoms, and especially to examine if there do not exist varieties more easy to cure. Dare we support this opinion, that indeed there exists and that one frequently meets a kind of epilepsy distinct by its phenomena and susceptible of being subjected to a useful method of treatment? Is this assertion going to expire, as so many others in the last pages of a thesis? " Thus writes Bravais in his introduction. Note that he has used the word "march," one that we are apt to attribute to Jackson-the march of the epileptic seizure. He goes on to say that he will treat of the principal varieties of epilepsy limited to one of the halves of the body and that he will call this hemiplegic epilepsy. He defends the name hemiplegic by saying this: "Now, epilepsy strikes the Postgrad Med J: first published as 10.1136/pgmj.11.114.150 on 1 April 1935. Downloaded from April, 1935 JACKSONIAN EPILEPSY 151 members with convulsions, as apoplexy strikes it with paralysis." This again sounds prophetic, for Jackson -was later to make great use of this comparison. Bravais goes on to accept the classification of epilepsy into idiopathic and sympathetic (reflex) varieties and finally to describe focal epilepsies under five headings, those that commence: (I) in the head, (2) in the arm, (3) those that irradiate from the foot, (4) those that commence in the abdomen or thorax, and lastly (5) those that depend on a local disease of the nerves. He observes that many seizures localized to one limb are sometimes followed by paralyses that may last for variable times--the post-epileptic palsy that we, in this country, attribute to R. B. Todd, of Guy's Hospital, and to Alexander Robertson. Bravais further states that epilepsy may affect a paralysed limb, and makes another astute observation, that if one limb of an epileptic is paralysed one may be sure that it was in that limb that the attacks originally commenced. But when one has selected these particular and undoubtedly very important passages one has done with Bravais, for it is clear that he has no conception of any physiological basis for the epileptic seizure even when most localized, and that his mind has not really been engaged on any profound interpretation of what he has observed. His intention, indeed, was to define a variety of epilepsy which he thought to be more curable, using the pharmacology of his day, than the generalized sort, and his method of cure was by the use of vesiculatory applications (especially cantharides) circularly around the distal portion of the limb that led in the attack. Bravais' statement that hemiplegic epilepsy is easier to cure than the by copyright. generalized variety opened up avenues of thought that his time was not ready to traverse. We might to-day accept Bravais' view, but only after profound modification. We should say that most cases of localized epilepsy carry a decipherable message, and that it is amongst these that we shall look for the cases most amenable to surgery. We should particularly underline the possible origin of such a fit in an often benign cerebral tumour. Enough has been said to indicate that Bravais was close to important dis- coveries, but that he did not make them, that certain of his observations are http://pmj.bmj.com/ acute, but that they are largely sterilized because his intention was in no way to unravel the pathogenesis of epilepsy, in no way to discover the reason why epilepsy might take the form which he had observed. It is most important that the limitations of his work should be fully understood. And how, after all, should Bravais press on to views which were revolutionary enough when Hughlings Jackson propounded them years later. For had not Flourens, the dominant physiologist of his age, only four years before the publication of on September 24, 2021 by guest. Protected Bravais' thesis, propounded his faith on the activities, or lack of them motorily, of the cerebral hemispheres? His experiments showed, or seemed to show, beyond all question and all doubt, that the hemispheres had nothing to do with movement. One or two extracts must be quoted from Flourens' famous Memoires given before the Academie Royale des Sciences of the Institute of Paris in 1822 and i823. " I removed," he writes, "on a small rabbit the two frontal bones: the animal lost little blood, and he was as well after the operation as before. I opened the dura mater of both sides; I opened the arachnoid also and separated the hemispheres; I then punctured the cerebral hemispheres in their whole extent, without producing anywhere the least sign of muscular contraction." Again: " I removed the cranial wall of the left side of a young dog; I punctured, I tore the cerebral lobes and the cerebellum of that side; the animal was neither dis- turbed nor agitated. I pricked, on an older dog, the quadrigeminal tubercles: as long as I injured only the superficial layers, that is to say only the tubercles, Postgrad Med J: first published as 10.1136/pgmj.11.114.150 on 1 April 1935. Downloaded from 152 POST-GRADUATE MEDICAL JOURNAL April, 1935 I saw no convulsions; when I touched, on the contrary, the cerebral peduncles, on which the tubercles rest, feeble convulsions appeared. I pricked the medulla oblongata: violent convulsions followed." Flourens had in previous experiments demonstrated that convulsions fol- lowed gross stimulations of the spinal cord and medulla. Here is an example: "I uncovered in a young dog the spinal cord in all its extent from the sacrum to the skull. Then I irritated, successively, all the points of this cord thus ex- posed, beginning at the caudal extremity; and I provoked at all these points phenomena of muscular contractions. I then opened the skull and I continued my irritations on the cerebral mass, and I soon found a point where these phe- nomena of muscular contraction ceased." A similar experiment showed the like results on a pigeon, on a frog, and on a rabbit: " Everywhere in the whole extent of these regions (spinal) on all these anifnals punctures and compressions were followed by convulsions." It is in these papers that Flourens gives his classical description of the behaviour of the animal deprived of its cerebral hemi- spheres, the blind and deaf animal that seemed to dream, but which responded by movement to all stimuli.